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Beim Umgang mit Brustkrebs ist Umdenken angesagt

 

Brustkrebs ist nach wie vor bei Nicht-Raucherinnen die häufigste Krebs-Todesursache. Im Gegensatz zum Gebärmutterkrebs, dessen Sterblichkeitsrisiko in den letzten sieben Jahrzehnten um 80% abgenommen hat, ist die Brustkrebssterblichkeit  seit 1930 nahezu gleich geblieben.

Die Bemühungen um Früherkennung - gefolgt von einer aggressiven Frühtherapie - haben sich offenbar als teurer Irrtum herausgestellt. Die Früherkennung eines nicht sehr aggressiven Tumors führt in einigen Fällen aufgrund der schweren Nebenwirkungen der Therapie zu Todesfällen, die es ohne diese Frühtherapien nicht gegeben hätte. Insofern wird der Nutzen der Mammografie dadurch wieder aufgehoben.
Der häufige Einsatz der Mammografie führte in den USA zu 5 Millionen falsch positiven Resultaten.

Experten fordern daher ein Umdenken hin zu einer Prophylaxe des Brustkrebses mit Hilfe von Arzneimitteln wie Tamoxifen.

 

 

 

Breast Cancer—Death Stats and Drug Prevention

February 12, 2002

By R.T. Ravenholt, M.D. M.P.H.

Breast cancer has remained the foremost cause of
cancerous death of U.S. women during this century for
those not smoking, despite much-publicized early
detection campaigns with aggressive surgery,
radiation therapy, chemotherapy, and anti-hormone
therapy. Unfortunately, the early detection and
aggressive treatment of breast cancers has failed to
achieve progressive reduction in national breast cancer
death rates
(Figure 1). By contrast, prevention of fatal
uterine cancer by early detection of neoplasia through
annual pelvic examinations and Pap smears, coupled
with ablative therapy and with some help from oral
contraceptive use and avoidance of smoking, has
reduced the age-adjusted death rate from uterine
cancer by 80 percent during the last seven decades —
a tremendous accomplishment!



Though their effects must be further studied, drugs
such as raloxifene and tamoxifen may provide an
opportunity for a revolutionary shift in the dominant
public health strategy against breast cancer: away
from early detection coupled with aggressive therapy,
toward a new era emphasizing prevention of breast
cancer with drug prophylaxis. These drugs will also be
generally used to prevent recurrence of breast cancer.
Additional means of breast cancer prevention will no
doubt be developed as research and medical practice
focus more fully upon primary prevention, but
raloxifene and tamoxifen provide a sound basis for
launching a national primary prevention campaign
against breast cancer, now numbering more than
180,000 new cases and 44,000 deaths annually in the
United States.

A Puzzling Enigma

How can it be that while there is general belief in the
value of early detection/treatment of breast cancer,
the national age-adjusted death rate from this disease
has remained relentlessly at the same high level for
several decades despite the large increase in the last
two decades in early mammographic detection
followed by aggressive therapy?

Understandably, this is because the claims of
therapeutic success have been largely based upon the
usual finding that a substantially higher proportion of
breast cancer patients diagnosed by mammography
and treated by surgery and radiation are alive five and
ten years following treatment than otherwise-identified
patients. Upon casual inspection, the salutary effects
of such treatment seem obvious, nicely fitting the
concept that early detection/treatment of breast
cancer saves many lives — as it certainly would if we
were dealing largely with cancers metaphorically
identified as "Rabbit Tumors" in the following
classification by George Crile:

"Bird Tumors" are cancers which are so highly
malignant and "flighty" that they ordinarily metastasize
before they can be successfully detected and treated.

"Rabbit Tumors" are cancers of intermediate
malignancy, becoming dangerously malignant and
"jumpy" with time, but curable by early detection and
treatment; witness cervical cancers and skin cancers.

"Turtle Tumors" are cancers inherently so weakly
malignant and indolent that they can ordinarily be
cured by ablation when they become apparent.

The most likely interpretation of the unyielding
continuation of traditional age-adjusted death rates
from breast cancer in the United States during this
century, despite heroic efforts at detection and early
drastic treatment, is that such cancers are mainly
"Birds" and "Turtles," for which surgery is less useful
than it is for "Rabbits," and thus early detection and
treatment — including costly and intrusive surgeries —
prevent few breast cancer deaths. Women are indeed
surviving for years after detection and treatment but,
on average, appear to be surviving no longer than they
would have without detection and treatment.

Elusive Benefits

Despite inadequate validation of the value of
mammography, a powerful combination of fearful
women, willing physicians and surgeons, merchants of
mammographic equipment and clinical services, health
agency bureaucrats, and politicians have ballooned the
use of mammography far beyond its demonstrated
intrinsic merits — to the point that in the United States
in 1994, 61% of women over age 40 (about 32 million)
reported having had mammograms during the past two
years.

 

Interpretations of these deca-millions of
mammograms increased diagnosed breast cancer
incidence and also generated more than 5 million false
positive diagnoses of breast cancer
— causing great
psychic and financial trauma to many millions of
women. The total health care costs generated by the
current exuberant practice of mammography in the
United States cannot be calculated exactly but surely
exceeds ten billion dollars annually.

The more than 100 million mammograms performed in
the United States during the last decade increased the
number of diagnosed breast cancer cases — and led
to treatments that often reduced quality of life — but
the wave of mammograms failed to reduce mortality
from breast cancer, which was at 25.1 deaths per
100,000 women in 1995 - the same level as in 1930
(Figure 1).

Mammographic screening is being promoted in the
belief that it leads to earlier diagnosis and treatment
and thereby extension of life. But one must be ever
mindful that it sometimes leads to a shortening of life
from "therapeutic misadventure" due to adverse
effects of surgery, radiation and chemotherapy
. Some
women who would have lived many years without
mammographic screening die an early death because
of early detection of incipient neoplasia and resultant
treatment. This seems a likely explanation for the
slight increase in breast cancer death rates seen in
the 1980s
(Figure 1) and may also be a reason for the
slight decrease in death rates seen in the early 1990s:
Some decrease in breast cancer deaths in the 1990s
would necessarily follow from the heaping of
"therapeutic misadventure" deaths in the 1980s,
causing some patients to die too early to appear in the
statistics for "natural deaths" from breast cancer in the
1990s. Although a death due to grievous adverse
effects of therapy should be certified as a "therapeutic
misadventure" and coded thereto, this rarely happens
because physicians ordinarily certify the death as due
to breast cancer: the diagnosis that led to the tragic
sequence of events. Increased use of the
anti-hormone tamoxifen for the prevention of breast
cancer recurrence probably has contributed to a slight
decrease in breast cancer mortality during the last few
years.

We do not know at exactly what level breast cancer
death rates would have been throughout this century if
there had been no aggressive detection and treatment
of breast cancer because breast cancer incidence and
fatality levels have been buffeted by a maelstrom of
determinants, sometimes acting synergistically and
sometimes conflicting: changes in childbearing and
breast-feeding, in nutrition and daily life, in
contraceptive use and smoking, in the detection and
treatment of breast cancer, in the occurrence of
competing causes of death and in the classification of
deaths by cause.
Yet we do know that excessive
promotion of mammographic screening in the 1980s and '90s has generated excessive agony and heavy costs for many millions of women, without much demonstrated utility.

The situation is reminiscent of the lung cancer control
campaigns of the 1950s and 60s, when the American
Cancer Society and many agencies urged all smokers
to have chest x-rays every six months for early
detection and treatment of lung cancer, thus diverting
smokers and the public from primary prevention and
providing profitable business for the
medical-industrial-complex but making no substantial
improvement in lung cancer five-year survival rates,
which continued at about 5%. This century's
experience has certainly demonstrated that the only
effective way to control lung cancer is by primary
prevention: by avoidance of the smoking of tobacco.

Likewise, clinical and public health practitioners must
now confront the tragic fact that the main breast
cancer control strategy of this century—early
mammographic detection followed by aggressive
surgery, radiation, and chemotherapy—has perhaps
been a costly, traumatic, and general failure.
Even the
desperate measure of bone marrow ablation and
transplant regeneration has failed to extend the lives of
those with progressive breast cancer.

For the suggested shift from reparative medicine to
breast cancer prevention
, there are immediately at
hand a precious few preventive measures of
demonstrated utility in the prevention of breast cancer:
the aforementioned raloxifene and tamoxifen, which
can cut breast cancer mortality among users to less
than half
, and preventive surgical enucleation of
glandular breast tissue, which can cut breast cancer
mortality among high-risk women by as much as 90
percent. A massive education effort for prevention is
needed to focus attention upon these lifesaving
measures.

R.T. Ravenholt, M.D. M.P.H.
Population Health Imperatives, Seattle, WA 98105
ravenrt@oz.net, www.ravenholt.com      

 

 

 

 

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